What is a hemorrhoid?
Hemorrhoids result from increased pressure in the veins of the anus causing them to bulge and expand, leading to significant pain, swelling, and bleeding. The most common cause is constipation and straining during bowel movements, sitting for prolonged periods of time, and/or anal intercourse. Two different types of hemorrhoids can occur: external or internal. More than 90% heal without surgery, and you will be given an appropriate bowel regimen and topical creams to provide relief as they heal. However, hemorrhoids that become chronic may require surgical treatment.
What are the symptoms of hemorrhoids?
While both external and internal hemorrhoids may cause bleeding, localized swelling, and thrombosis, the key difference between the two is that external hemorrhoids generally cause pain while internal do not. Sometimes external thrombosed hemorrhoids develop skin tags in the region due to the overlying skin being stretched. See skin tag.
How are hemorrhoids diagnosed?
Most external hemorrhoids can be diagnosed via clinical inspection, while internal hemorrhoids are examined by anoscopy.
What is the treatment for hemorrhoids?
Non-Surgical Hemorrhoid Treatments
There are ways to attempt to treat hemorrhoids from home. The appropriate initial non-surgical regimen to treat hemorrhoids consists of:
- Over-the-counter stool softeners, such as Colace, three times daily
- Over-the-counter fiber supplements, such as Metamucil
- Sitz baths, utilizing over-the-counter epsom salts
- Proctozone 2.5% or a similar steroid, a prescription topical anal ointment, should be applied as directed by your physician.
- Boosting your fiber intake with choices such as grains and whole-grain products, fruits, vegetables, legumes, nuts, and seeds
- Increasing your overall water intake to 8-12 ten ounce glasses per day
- Keeping the anal area clean and dry. Wash gently with warm soapy water, and pat dry.
- Limiting the use of toilet paper, as wiping causes local inflammation. Please refrain from using baby wipes or medicated pads for prolonged periods, and do not spend more time sitting on the toilet than necessary.
Anal pathology takes time to heal. You can imagine that every time it is attempting to improve, another local trauma/bowel movement occurs. Do not try to avoid having bowel movements, and try not to get frustrated as you work on the above regimen. We will see you in 2-3 weeks from initial diagnosis to see what improvement has occurred. Surgery is the last option in our management.
Anal Hemorrhoid Surgical Treatment
Non-surgical hemorrhoid treatments are very effective, but unless dietary and lifestyle changes are made, they may recur. If symptoms persist or are severe, an anal hemorrhoid surgeon may be required to provide one of the following treatments:
- Cauterization – Using either an electric probe, a laser beam, or an infrared light, a burn seals the end of the hemorrhoid, causing it to close off and shrink.
- Banding – Prolapsed internal hemorrhoids are often removed using rubber-band ligation in the office. A special instrument secures a tiny rubber band around the hemorrhoid shutting off its blood supply, causing it to fall off within a week. Banding is not an option for large internal hemorrhoids or ones that encroach externally. If placed on ones with that mild muscle or external component, it can be quite uncomfortable and without efficacy.
- Anal Hemorrhoid Surgery – For large internal hemorrhoids, uncomfortable external hemorrhoids, mild thrombosed hemorrhoids, or mild hemorrhoids with large remaining skin tags, a hemorrhoidectomy is warranted by an anal hemorrhoid surgeon. Formal hemorrhoidectomy is a wonderful approach in the gay community, since it allows also for removal of tags and restoration of the canal to allow for maximal pleasure, with the aesthetics one desires. Another anal hemorrhoid surgical option is called the procedure for prolapsed hemorrhoids (PPH). This is using a circular device and stapling the hemorrhoidal tissue in a 360 degree manner. It is highly effective, though in the anal intercourse world it is not recommended since the staple line internally will be present; leading to irritation, pain, and an adverse outcome for the giver.
The location of the hemorrhoid that is targeted and surgically removed affects whether the region excised is closed primarily with sutures or left open to heal by secondary intention. Clearly, one would love to close all areas, but understanding both the anatomy and healing capacities of such, limits what one can do intra-operatively. This leads to changes in the post-operative course that one should be aware of.
- Sutures in Place – Leave the absorbable stitches alone. There are two rows–one continuous and the other interrupted–that keep all intact. However, this is not like a cut on the arm or torso, which has limited forces against healing. We have to defecate daily and this act causes significant pressures to be had in the anal region. This, in turn, can cause stress and strain on the stitch work. Do not fret if some or all of the stitches open up. I am expecting some to do so, hence why we do two rows and place several in that region. Continue to follow instructions on the use of creams, stool softeners, and Epsom salt baths. Do not use suppositories in the immediate post-operative period and refrain from inserting anything into the anus unless instructed, such as Preparation H creams. The key is to keep everything clean and dry, as well as use more abrasive exfoliating soaps to help along the healing process. Place a piece of gauze to catch any excrement, such as drainage, which is quite normal. This will heal nicely even if opened. In the office, I will remove any unwanted lingering sutures and cauterize the open wound. This will encourage closure and will heal aesthetically as planned. Of course, let us know if opening occurred and we can spearhead the above to ensure appropriate healing.
- Wound Left Open – This, again, is strategically done due to the hemorrhoid’s location and these heal quite fast with the aesthetic result we all intended. In this case, using suppositories, like Calmol-4, is suggested, along with Preparation H, stool softeners, and Epsom salt baths. Exfoliating soaps, once one can tolerate, are key to getting rid of the daily grime that develops. The body’s normal mechanism is to produce mucus to cover the open wound; however, the mucus limits healing, which is why I recommend a twice daily routine of exfoliation to get rid of this. In the office, during the initial 3 and 6 week post-operative visits, I will cauterize the open wound to encourage healthy tissue and subsequent closure.
- Both Closed and Open Wounds – Some people have both open and sutured regions following their surgical procedures, specifically if there is multiple hemorrhoids and tags needing removal. Please follow the sutured algorithm if this is indeed the case.
- Botox – In many hemorrhoidal cases, we utilize Botox to assist in relaxation, which ultimately improves healing and subsequently anal engagement. Botox takes 2-3 days to start working and the action is to loosen that region. One will not defecate on the street, per se, but if you feel the need to pass gas or to defecate, I suggest going to the bathroom sooner rather than later. People do get more of a sense of urgency and flatulence, which can lead to limited control in the initial immediate postoperative period, specifically when we are using gentle laxatives and softeners to assist healing and minimize pain. This will improve daily and usually is present during the first one to two weeks. Remember: Botox in these cases is key to the healing process and is imperative to its success.
- Tags Developing – Do not fret if some new small skin tags develop in the suture or wound lines. This can happen and is a normal process. During the initial postoperative visit, they are easily handled in the office with local treatments to rid and encourage appropriate outcomes.
- Infections – Very rarely in the closed format an infection may develop. Redness and purulent drainage can occur usually post op days 3-7 and it’s more of a detour away from positive daily improvement. One may see some swelling and the above localized redness, along with potential fevers and chills. Please let us know if you experience this so that we may prescribe antibiotics and possible drainage, if necessary. Though rare, it can happen and we should all be knowledgeable on this unfortunate outcome. Even if this occurs, everything is manageable.
- Discoloration and Loss of Melanin – In darker skin types, a disclaimer pre and post operatively is warranted as scars can heal with a loss of pigment. Please understand that this is not a surgical complication, but rather more about the healing within specific skin types. It is still rare, but if it happens, even though most of the time they go unnoticed, one can bleach the region to blend its lighter, pinker scar line or have that patch of skin tattooed to match the surrounding skin.
- Packing – I place a piece of packing in the anal canal in all of my surgical patients. This is to stop any unwanted bleeding. It will come out during the first defecation and looks like a piece of skin. Do not fret. It is not your skin and if you do see it in the toilet bowl, it is normal and should be flushed away.
Following these postoperative instructions and understanding the entire healing process for both open and closed wounds, with or without Botox, will maximize not only the recovery, but also allow for appropriate healing and the ultimate functional and aesthetic results we all are seeking.
Bespoke Surgical has offices in Beverly Hills, LA and Lower Manhattan, New York City that provide hemorrhoid surgical solutions. If you’re looking for a hemorrhoid surgeon, contact our offices today.
Recovering from Hemorrhoid Surgery
1 to 3 Days post-op – For the first 24 hours after your hemorrhoid surgery, you should not drive, operate heavy machinery, make important decisions, or sign legal documentation. You should also refrain from consuming alcohol and large or heavy meals. The patient should be prepared to experience discomfort in the first two to three days. I recommend using prescribed pain medication along with lotions, suppositories, and anti-inflammatories to assist in all facets of recovery. You most probably will need to use painkillers for the first 24-72 hours after hemorrhoid surgery and then I recommend switching to Tylenol or Ibuprofen for the next one to two weeks.
2 to 5 Days post-op – It is common to not have a bowel movement for 2-3 days after your hemorrhoid surgery, so stay well hydrated, eating fruits and vegetables daily, and consider taking a mild laxative to help this process along. You may need to use painkillers for the first 24-72 hours after hemorrhoid surgery. On day 3, we recommend switching to Tylenol or Ibuprofen. You will need to avoid stress to the operative site (such as lifting, pushing, and pulling) for 3-5 days.
1 to 2 Weeks post-op – Epsom salt baths are a lifesaver and assist in not only the healing process, but also pain control as well.
And of note, most anal procedures, including hemorrhoid surgery, see full healing around 6-8 weeks, with us seeing you two times during this period to assist in the healing process.
Some specifics most clients ask:
Exercise after hemorrhoid surgery – Most clients head back to the gym about a week after their procedure and do limited gluteal work until all feels improved—roughly two to three weeks.
Intercourse after hemorrhoid surgery – The majority engage by topping or vaginal intercourse in about one week after their procedure. We do recommend masturbation first, making sure all works well, since during orgasm, most contract their pelvic floor and this may lead to pain.
Submerging in water after hemorrhoid surgery – I am totally fine with pools, jacuzzis, and/or the ocean, and do believe getting active in these environments assists healing. We would recommend these activities about 2-3 days post surgery and do recommend showering directly after and following the usual post-cleansing rituals.
To learn more about what to expect during postoperative recovery from hemorrhoid surgery, please visit our Frequently Asked Questions.
“I was always more of a top, but met someone who requested some role reversal. That first night was intimate and exactly what we had both hoped for. Anal intercourse didn’t hurt that evening and it was the most sensual bottoming experience I had ever had. With that said, my happy ending didn’t last long. The next morning, I awoke with what I thought was a grape on the rim of my anus. It was quite painful and progressed over the subsequent days. I finally decided it was time to see my primary care physician and was placed on local steroid ointment and Motrin. Along with Epsom salt baths, the immediate hemorrhoid improved; however, over the next couple of months, recurring episodes and flare ups caused me to seek an anal surgeon in New York, who not only specialized in hemorrhoids, but also understood why bottoming caused the hemorrhoid initially and how I could prevent it from happening again. I felt so at ease with Dr. Goldstein during my consultation. I knew I wouldn’t be judged expressing how the hemorrhoid caused me such grief and I can’t express how glad I was to finally get rid of it. Not to mention, because of Dr. Goldstein’s complete understanding of the male body, the aesthetics are back to being “top” notch, too.”